Daily co-occurrence of alcohol use and high-risk sexual behavior among heterosexual, heavy drinking emergency department patients
Introduction
Unsafe sex (i.e., unprotected sex that could lead to sexually transmitted infections [STI] and/or unintended pregnancies) is a significant cause of disease and disability (Glasier et al., 2006). Indeed, 6.2% of all disability-adjusted life years is attributable to unprotected sexual behavior in the United States (Ebrahim et al., 2005), and the annual direct medical costs associated with STIs topped $15.6 billion dollars in 2008 (Owusu-Edusei et al., 2013). The resurgence of previously well-controlled STIs (e.g., syphilis; Mattei et al., 2012) and growing treatment resistance (CDC, 2013) suggest that the STI-related burden may grow substantially in the near future, highlighting the importance of research into factors contributing to unsafe sex.
Alcohol use has been implicated as a key factor in the spread of STIs (Cook and Clark, 2005, Schneider et al., 2012), due in part to findings from cross-sectional (Grossman and Markowitz, 2005, Sen, 2002) and experimental findings (Rehm et al., 2012) supporting a relationship between alcohol use and unsafe sex. However, design limitations of these studies prevent conclusive inferences about the alcohol-unsafe sex link. Cross-sectional studies focusing on overall involvement in alcohol use and sexual risk (e.g., “over the past 6 months”) cannot establish the temporal proximity of the two behaviors. Moreover, experimental studies examine unprotected sex intentions using hypothetical scenarios. While there is evidence that intentions to use condoms are a robust predictor of condom use (Albarracin et al., 2001, Reinecke et al., 1996), important differences may exist between intentions rated in laboratory settings and real world behavior.
Situational association studies address these limitations by exploring whether alcohol use co-occurs with unsafe sex on the same occasion in naturalistic contexts. Early meta-analyses of event-level studies found that alcohol appeared to be unrelated to increased unsafe sex (Leigh, 2002, Weinhardt and Carey, 2000), but most of these studies explored their co-occurrence on just a few occasions (e.g., first sex, last sex). Studies utilizing more intensive assessments (e.g., cross-sectional daily recall or longitudinal designs) have the potential to explore whether alcohol and unsafe sex co-occur across many days, drinking occasions, and sex events over a given time period. Several such studies have been conducted since the aforementioned meta-analyses were published, and suggest that alcohol use consistently increases the likelihood of sex, but that the use of protection may depend on partner factors. For example, one daily diary study (Kiene et al., 2009) and two studies using situation and day-level recall assessments (Brown and Vanable, 2007, LaBrie et al., 2005) showed that drinking increased the odds of unprotected sex specifically with casual partners. However, at least one daily recall study found the opposite. Heavy drinking was associated with unprotected sex only with steady partners, and this relationship was significant only among women (Scott-Sheldon et al., 2010b). Moreover, one daily diary study found that alcohol use was not associated with condom use (Morrison et al., 2003). As such, while situational association studies are critical to understanding whether alcohol use increases unsafe sex in the real world, findings from these studies have been mixed. The vast majority of these studies have also focused on adolescents and college students. Although this may be warranted because of elevated STI risk among young adults (CDC, 2012), few studies have explored the alcohol-unsafe sex link in a broader range of adults or among those who drink heavily. Hence, findings from past studies on this link may be difficult to generalize beyond college students and young adults.
This study addresses this gap in the literature by examining the day-level co-occurrence between alcohol use level and sexual behavior in a sample of heavy-drinking emergency department patients who have engaged in some sexual risk behavior in the past 3 months (i.e., unprotected sex with a casual partner or unprotected sex with a steady partner who's fidelity is questioned or known). We used a cross-sectional daily assessment method (Timeline Followback; TLFB) to explore the association between alcohol use level and three key sex outcomes on a given day: The occurrence of (1) any sex, (2) unprotected intercourse (UI) with either steady or casual partners (versus protected intercourse [PI]), and (3) UI with a casual partner (versus “safer” forms of sex, such as PI with casual partners and/or UI/PI with a steady partner). These three variables allowed us to examine the association of alcohol use with engaging in any sex at all versus sex that is associated with increasing levels of risk. Given our study inclusion criteria, UI with any type of partner conveys some risk. However, because this outcome includes UI with steady partners, the risk for STI transmission may be lower for this outcome, since it may be more likely to involve risk reduction efforts other than condom use (e.g., sexual exclusivity, discussion of sexual history and STI status, use of alternative methods of contraception). UI with casual partners (versus PI with a casual partner or PI/UI with a steady partner), however, likely conveys the highest risk of the three. Based on past findings (e.g., Brown and Vanable, 2007, Kiene et al., 2009, LaBrie et al., 2005, Morrison et al., 2003), we hypothesized that higher levels of alcohol use, specifically use indicative of intoxication (i.e., consuming 5–11, or 12+ drinks on a given day for men, or 4–9, or 10+ drinks for women) would be uniquely associated with an increased odds of engaging in UI with casual partners versus engaging in “safer” forms of sex.
Section snippets
Materials and methods
This study used baseline data from 371 patients seeking medical treatment in the ED who enrolled in a randomized trial of a brief, combined intervention for alcohol and sex risk. This broader study explored whether a brief, motivational interviewing intervention could reduce heavy drinking and sexual risk behavior compared with brief advice. Inclusion criteria were: (1) Scores >8 for men and >6 for women on the Alcohol Use Disorders Identification Test (AUDIT; Babor et al., 2001) or >1 episode
Descriptive statistics
See Table 1 for demographics. Although the demographic characteristics of ED patients meeting criteria for “hazardous drinking” varies considerably across studies, fewer participants in our sample were married (likely due to our sexual risk eligibility criterion) but were otherwise similar to past studies conducted in EDs (e.g., Cherpitel, 1995, Neumann et al., 2004). TLFB data were entirely complete, with 0% of days missing. Thus, participants provided 9660 person-days of data across the
Discussion
This study is among the first to examine day-level relationships between alcohol use and sexual risk behaviors among heavy drinking, heterosexual emergency department patients. It is unique in its exploration of these associations in a more diverse sample with heavier drinking patterns than past studies. Using TLFB data, we examined whether alcohol use level on a given day was associated with engagement in sex, the use of protection during sex, and the type of partner (“casual” versus “steady”)
Role of funding source
This research was supported by NIAAA grant R01AA009892 and T32AA007459 to Peter M. Monti, and L30AA02336 to Tyler B. Wray.
Contributors
Tyler Wray conducted the analysis and interpretation of the data and prepared the manuscript.
Mark Celio assisted in the analysis and interpretation of the data and prepared preliminary versions of the methods section.
Christopher Kahler contributed to the conception and design of the study, assisted in data collection, assisted in the analysis of data, and revised drafts of the manuscript.
Nancy Barnett contributed to the conception and design of the study, assisted in data collection, and
Conflict of interest
The authors have no conflicts of interest to declare.
References (61)
- et al.
Global epidemiology of HIV infection in men who have sex with men
Lancet
(2012) - et al.
Alcohol use, partner type, and risky sexual behavior among college students: findings from an event-level study
Addict. Behav.
(2007) Screening for alcohol problems in the emergency department
Ann. Emerg. Med.
(1995)Sexually transmitted diseases enhance HIV transmission: no longer a hypothesis
Lancet
(1998)- et al.
Sexual and reproductive health: a matter of life and death
Lancet
(2006) - et al.
Alcohol, helping young adults to have unprotected sex with casual partners: findings from a daily diary study of alcohol use and sexual behavior
J. Adolesc. Health
(2009) - et al.
Sexually-transmitted disease in female adolescents: effects of psychosocial factors and high risk behaviors
J. Adolesc. Health
(1995) Does alcohol-use increase the risk of sexual intercourse among young people? Evidence from the NLSY97
J. Health Econ.
(2002)- et al.
Convergent Validity: An Approach to Increasing Confidence in Treatment Outcome Conclusions with Alcohol and Drug Abusers. Evaluating Alcohol and Drug Abuse Treatment Effectiveness: Recent Advances
(1980) - et al.
Reliability of alcohol abusers’ self-reports of drinking behavior
Behav. Res. Ther.
(1979)
Developing a Prototype for Evaluating Alcohol Treatment Effectiveness. Evaluating Alcohol and Drug Abuse Treatment Effectiveness: Recent Advances
Theories of reasoned action and planned behavior as models of condom use: a meta-analysis
Psychol. Bull.
The Alcohol Use Disorders Identification Test. Guidelines for Use in Primary Care. Washington, DC
Sexual risk among injection drug users recruited from syringe exchange programs in California
Sex. Transm. Dis.
Gender perspectives and STDs
Assessing sexual risk behaviour with the Timeline Followback (TLFB) approach: continued development and psychometric evaluation with psychiatric outpatients
Int. J. STD AIDS
Sexually Transmitted Disease Surveillance, 2011
Gonorrhea Treatment Guidelines: Revised Guidelines to Preserve Last Effective Treatment Option
The AUDIT questionnaire: choosing a cut-off score
Addiction
Is there an association between alcohol consumption and sexually transmitted diseases? A systematic review
Sex. Transm. Dis.
Nature, decay, and spiraling of the effects of fear-inducing arguments and HIV counseling and testing: a meta-analysis of the short-and long-term outcomes of HIV-prevention interventions
Health Psychol.
Sexual behaviour: related adverse health burden in the United States
Sex. Transm. Infect.
The timeline followback reports of psychoactive substance use by drug-abusing patients: psychometric properties
J. Consult. Clin. Psychol.
Sexual hookup culture: a review
Rev. Gen. Psychol.
Indirect effects of acute alcohol intoxication on sexual risk-taking: the roles of subjective and physiological sexual arousal
Arch. Sex. Behav.
Risks of alcohol use disorders related to drinking patterns in the US general population
J. Stud. Alcohol Drugs
I did what last night?!!! Adolescent risky sexual behaviors and substance use
East. Econ. J.
Rethinking gender, heterosexual men, and women's vulnerability to HIV/AIDS
Am. J. Public Health
Daily associations between alcohol use and unprotected anal sex among heavy drinking HIV-positive men who have sex with men
AIDS Behav.
Sexual coercion, domestic violence, and negotiating condom use among low-income African American women
J. Womens Health
Cited by (10)
Substance use patterns through early adulthood: Results for youth with and without chronic conditions
2016, American Journal of Preventive MedicineCitation Excerpt :For YCMC, alcohol may negatively interact with over-the-counter and prescription medications,15 and alcohol and other substance use may impact treatment adherence: A recent investigation found that the risk for medication non-adherence among YCMC who drink compared with those who do not was nearly double.16 Moreover, substance use carries risks for poor sleep, unhealthy diet, and unprotected sex with attendant risks from sexually transmitted disease and pregnancy,17–19 particularly devastating for youth taking immune-suppressing or teratogenic medications. Both substance use and chronic disease impose heavy morbidity burdens on the unfolding lives of young people, including during periods of added vulnerability when they are transitioning care.20
Impact of alcohol use on sexual behavior among men who have sex with men and transgender women in Lima, Peru
2016, Drug and Alcohol DependenceCitation Excerpt :The prevalence of AUDs/STIs among heterosexual individuals might also be higher than that of the general population if recruited from similar clinical settings using similar inclusion criteria. Especially since several studies have shown associations between alcohol use and the sexual risk behaviors that increase one’s risk for HIV/STI acquisition among heterosexuals (Wray et al., 2015; Cook and Clark, 2005; Schneider et al., 2012; Fisher et al., 2007; Vagenas et al., 2013; Sen, 2002). One potential life stress we identified that may be contributing to AUDs and sexual risk behaviors was the history of prior sexual coercion as this finding was significantly higher among those with more severe AUDs (hazardous and dependent drinkers).
The effect of expressive writing on sexual risk behavior among college women
2022, Journal of American College HealthCorrelation between alcohol drinking and high risk sexual behaviors in HIV negative clients of female sex workers
2020, Chinese Journal of EpidemiologyDrug-taking in a socio-sexual context enhances vulnerability for addiction in male rats
2019, Neuropsychopharmacology